Neck Pain Questionnaire

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1. How bad is your neck pain?* This field is required. (0/10 = no pain, 10/10 = take me to hospital)
4/10 No pain medication is needed
5/10 Still no pain medication is needed
6/10 Pain medication gives me relief
7/10 Pain medication gives me MODERATE relief
8/10 Pain medication gives me LITTLE relief
10/10 Pain medication gives NO relief
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2. Personal care (washing, dishes, dressing etc)* This field is required.
I look after myself normally without causing extra neck pain
I look after myself normally, but it causes extra neck pain
It is painful to look after myself and I am slow and careful
I need some help but can manage most of my personal care
I need help everyday in most aspects of self care
I do not get dressed or wash by myself, and cannot get out of bed without assistance
3
3. How do you feel when lifting?* This field is required.
I can lift heavy weights with no neck pain
I can lift heavy weights normally, but it causes extra neck pain
It is too painful to lift things off the floor, but can manage if they are conveniently placed, eg. on a table
I can lift light to medium weights if they are conveniently positioned
I can only lift very light weights
I cannot lift or carry anything
4
4. How do you feel reading?* This field is required.
I can read any amount without pain
I can read as much as I want with slight pain in my neck
I can read as much as I want with moderate pain in my neck
I cannot read as much as I want due to moderate pain in my neck
I cannot read as much as I want due to severe pain in my neck
I cannot read at all
5
5. How do you feel sleeping?* This field is required.
I can sleep comfortably
My sleep is slightly disturbed (less than 1 hour sleepless)
My sleep is mildly disturbed (1–2 hours sleepless)
My sleep is moderately disturbed (2–3 hours sleepless)
My sleep is greatly disturbed (3–5 hours sleepless)
My sleep is completely disturbed (5–7 hours sleepless)
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6. How is your concentration?* This field is required.
I can concentrate fully when I want to with no difficulty
I can concentrate fully when I want to with slight difficulty
I have a fair degree of difficulty in concentrating when I want to
I have a lot of difficulty in concentrating when I want to
I have a great deal of difficulty in concentrating when I want to
I cannot concentrate at all
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7. Do you suffer with headaches?* This field is required.
I have no headaches
I have slight headaches which come infrequently
I have moderate headaches which come infrequently
I have moderate headaches which come frequently
I have severe headaches which come frequently
I have headaches almost all the time
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8. How is your social life affected by your neck pain?* This field is required.
My social life is normal and gives me no extra neck pain
My social life is normal but increases the degree of pain
Pain has no significant affect on my social life apart from limiting my more energetic interests, eg. sport
Pain has restricted my social life and I do not go out as often
Pain has restricted my social life to my home
I have no social life because of my neck pain
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9. How does your neck pain affect your driving?* This field is required.
I can drive anywhere without pain
I can drive anywhere but it gives me extra pain
I can drive my car as long as I want, with moderate pain in my neck
I cannot drive my car as long as I want, because of moderate pain in my neck
I can hardly drive at all because of severe pain in my neck
I cannot drive my car at all
10
10. How does your back pain affect your work and home life?* This field is required.
My normal work/home activities do not cause pain
My normal work/home activities increase my pain, but I can still perform all that is required of me
My normal work/home activities are possible but pain prevents me from performing more physically stressful activities (eg vacuuming, lifting)
Pain prevents me from doing anything but light duties
Pain prevents me from doing even light duties
Pain prevents me from doing any work or home chores
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Full Name* This field is required.
First Name
Last Name
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Phone Number* This field is required.
Area Code
Phone Number
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email* This field is required.
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